HHS Finalizes Essential Health Benefits Provisions

Yesterday, the Department of Health and Human Services (HHS) finalized provisions in the Affordable Care Act ensuring that health plans offered in the individual and
small group markets, both inside and outside of health insurance marketplaces (also called "exchanges") offer a core package of items and services, known as essential health benefits (EHB).

Beginning in 2014, all nongrandfathered health insurance coverage in the individual and small group markets, Medicaid benchmark and benchmark-equivalent plans, and basic health programs (if applicable) will cover EHB, which include items and services in 10 statutory benefit categories, including rehabilitation and habilitation services and devices. These benefits will be equal in scope to a typical employer health plan.

The final rule defines EHB based on a state-specific benchmark plan. States can select a benchmark plan from among several options, including the largest small group private health insurance plan by enrollment in the state. The final rule provides that all plans subject to EHB offer benefits substantially equal to the benefits offered by the benchmark plan.

The final rule also includes standards to protect consumers against discrimination and ensure that benchmark plans offer a full array of EHB benefits and services.

Substitution within EHB categories is still permissible to provide greater choice to consumers and promote plan innovation through coverage and design options. The requirement that any substitution must be actuarially equivalent is retained in the final rule. It is up to each state to set criteria for substitution.

HHS does not provide a federal definition of habilitative services in this final rule. If habilitative services are not yetcovered by the EHB-benchmark plan, then states have the first opportunity to determine which habilitative benefits must be covered by their benchmark plan. States may choose either the
definition used by the National Association of Insurance Commissioners or Medicaid. If states have not chosen to define habilitative benefits, the health plan issuers' will
determine the benefit. This is a transitional policy, and HHS intends to monitor available data regarding coverage of habilitative services.

HHS also finalizes actuarial values (AVs), also called "metal levels," to assist consumers in comparing and selecting health plans by allowing a potential enrollee to compare the relative payment generosity of available plans. Nongrandfathered health insurance plans must meet 1 of 4 specific AVs: 60% for a bronze plan, 70% for a silver plan, 80% for a gold plan, and 90% for a platinum plan.

APTA was highly involved in the processes that determined how EHBs should be defined. The association submitted comments to HHS in response to a December 2011 guidance bulletin, the Center for Consumer Information and Insurance Oversight's January 2012 bulletin, and the Institute of Medicine's report Essential Health Benefits: Balancing Coverage and Cost. APTA also took part in all public stakeholder meetings. Throughout the development of EHB, APTA urged HHS' secretary not to overly define the categories so that practitioners have the flexibility to provide both the type and frequency of care that is medically necessary for each individual.